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FFR和血管造影指导下多支血管PCI治疗心肌梗死的比较
Multivessel PCI Guided by FFR or Angiography for Myocardial Infarction


Etienne Puymirat ... 心脑血管疾病 • 2021.07.22
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FLOWER-MI研究:FFR指导介入治疗不再战无不胜

 

刘巍*,高雅楠

首都医科大学附属北京安贞医院心内科

*通讯作者

 

血流储备分数(FFR)似乎从诞生的那一天起,就是冠心病介入治疗界的“宠儿”——在指导冠状动脉介入治疗的诸多手段中,FFR俨然被推崇为一个最公正的“法官”,秉承着“不错杀一个好人”的原则。FAME、FAME-2、DEFER等研究奠定了FFR在指南当中的重要地位1-3。FFR已经成为判定稳定临界病变是否需要进行冠状动脉治疗的金标准。DANAMI-3研究也证实,STEMI合并多支病变的患者中,应用FFR指导非梗死血管相关的完全血运重建相对于仅仅治疗梗死血管,能明显降低远期事件的发生率4

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摘要


背景

在有多支血管病变的ST段抬高型心肌梗死(STEMI)患者中,对非罪犯病变行经皮冠状动脉介入治疗(PCI)(完全血运重建)优于仅对罪犯病变实施治疗。然而,血流储备分数(FFR)指导下的完全血运重建是否优于血管造影指导下的完全血运重建尚不明确。

 

方法

在此项多中心试验中,我们将已成功接受梗死相关动脉PCI的多支血管病变STEMI患者随机分组,两组分别接受FFR和血管造影指导下的完全血运重建。主要结局是由1年时的全因死亡、非致死性心肌梗死或导致紧急血运重建的计划外住院构成的复合结局。

 

结果

在FFR指导组和血管造影指导组中,每例患者因非罪犯病变置入的支架平均(±SD)数量分别为1.01±0.99个和1.50±0.86个。随访期间,FFR指导组586例患者中的32例(5.5%)和血管造影指导组577例患者中的24例(4.2%)发生了主要结局事件(风险比,1.32;95%置信区间[CI],0.78~2.23;P=0.31)。FFR指导组9例(1.5%)和血管造影指导组10例(1.7%)患者死亡,两组分别有18例(3.1%)和10例(1.7%)患者发生非致死性心肌梗死,两组分别有15例(2.6%)和11例(1.9%)例患者发生导致紧急血运重建的计划外住院。

 

结论

在接受完全血运重建的STEMI患者中,在1年时的死亡、心肌梗死或紧急血运重建风险方面,FFR指导策略与血管造影指导策略相比并无显著益处。然而,鉴于效应估计值的置信区间较宽,因此我们无法对上述结果做出明确解读(由法国卫生部[French Ministry of Health]和雅培资助,FLOWER-MI在ClinicalTrials.gov注册号为NCT02943954)。





作者信息

Etienne Puymirat, M.D., Ph.D., Guillaume Cayla, M.D., Ph.D., Tabassome Simon, M.D., Ph.D., Philippe G. Steg, M.D., Gilles Montalescot, M.D., Ph.D., Isabelle Durand-Zaleski, M.D., Ph.D., Alicia le Bras, M.D., Romain Gallet, M.D., Ph.D., Khalife Khalife, M.D., Jean-François Morelle, M.D., Pascal Motreff, M.D., Ph.D., Gilles Lemesle, M.D., Ph.D., Jean-Guillaume Dillinger, M.D., Ph.D., Thibault Lhermusier, M.D., Ph.D., Johanne Silvain, M.D., Ph.D., Vincent Roule, M.D., Ph.D., Jean-Noel Labèque, M.D., Grégoire Rangé, M.D., Grégory Ducrocq, M.D., Ph.D., Yves Cottin, M.D., Didier Blanchard, M.D., Anaïs Charles Nelson, N.D., Bernard De Bruyne, M.D., Ph.D., Gilles Chatellier, M.D., and Nicolas Danchin, M.D. for the FLOWER-MI Study Investigators*
From Assistance Publique–Hôpitaux de Paris (AP-HP), Department of Cardiology, Hôpital Européen Georges Pompidou, Université de Paris, INSERM, Paris Centre de Recherche Cardiovasculaire (E.P., D.B., N.D.), AP-HP, Hôpital Saint Antoine, Department of Clinical Pharmacology and Unité de Recherche Clinique, Sorbonne Université, INSERM Unité 698 (T.S.), Université de Paris, INSERM Unité 1148, and Hôpital Bichat, AP-HP (P.G.S.), Sorbonne Université, ACTION Study Group, Institut de Cardiologie (AP-HP), INSERM UMRS 1166, Hôpital Pitié–Salpêtrière (G.M., J.S.), Clinical Research Unit Eco Ile de France, Hôpital Hôtel Dieu, AP-HP (I.D.-Z., A.B.), the Department of Cardiology, Hôpital Lariboisière, AP-HP, INSERM Unité 942, Université de Paris (J.-G.D.), the Department of Cardiology, Hôpital Bichat, AP-HP, French Alliance for Cardiovascular Trials, INSERM Unité 1148, Laboratory for Vascular Translational Science, Université de Paris (G.D.), the Clinical Research Unit and Centre d’Investigation Clinique 1418 INSERM, George Pompidou European Hospital, AP-HP (A.C.N., G. Chatellier), and the French Alliance for Cardiovascular Trials (E.P., T.S., P.G.S., G.L., D.B., G.D., N.D.), Paris, Centre Hospitalier Universitaire (CHU) de Nîmes, Nîmes (G. Cayla), Service de Cardiologie, AP-HP, Université de Paris Est Créteil, Hôpitaux Universitaires Henri Mondor, Créteil, and Unité 955–Mondor Institute for Biomedical Research, Equipe 03, INSERM, Ecole Nationale Vétérinaire d’Alfort, Maisons-Alfort (R.G.), Hôpital du Bon Secours, Metz (K.K.), Clinique St. Martin (J.-F.M.) and the Cardiology Department, Caen University Hospital (V.R.), Caen, the Department of Cardiology, CHU Clermont-Ferrand, CNRS UMR 6602, Université Clermont Auvergne, Clermont-Ferrand, the Cardiac Intensive Care Unit, Heart and Lung Institute, CHU Lille (P.M.), and the Heart and Lung Institute, University Hospital of Lille, Institut Pasteur of Lille, INSERM Unité 1011 (G.L.), Lille, and the Intensive Cardiac Care Unit, Department of Cardiology, Rangueil University Hospital, and the Medical School, Toulouse III Paul Sabatier University, Toulouse (T.L.), Groupement de Coopération Saintaire de Cardiologie de la Côte Basque, Centre Hospitalier de la Côte Basque, Bayonne (J.-N.L.), the Cardiology Department, Hôpitaux de Chartres, Chartres (G.R.), and Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires, Equipe d’Accueil (EA 7460), University of Bourgogne Franche-Comté, and the Cardiology Department, University Hospital Center of Dijon Bourgogne, Dijon (Y.C.) — all in France; Cardiovascular Center Aalst, Aalst, Belgium (B.D.B.); and the Department of Cardiology, Lausanne University Center Hospital, Lausanne, Switzerland (B.D.B.). Address reprint requests to Dr. Puymirat at the Department of Cardiology, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France, or at etienne.puymirat@aphp.fr. *A list of the FLOWER-MI study investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

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